A while back you may remember the creator of Minecraft, Notch, announcing Mojang’s next game, Scrolls. It was going to be a sort of fantasy/strategy game though details past its initial announcement were scarce.
Flash forward to now and Bethesda filed a complaint to Swedish courts against Mojang over their filing for the trademark, “Scrolls,” feeling that the name infringes on their own game series, “The Elder Scrolls.”
Notch explains on his tumblr that after being contacted by Bethesda’s lawyers for more information concerning the trademark, he attempted to make a compromise to help differentiate Mojang’s Scrolls from Bethesda’s The Elder Scrolls, like adding words after the word scrolls instead of before like, “Scrolls – The Banana Explosion.”
I would pay any amount of money for that game.
Unfortunately, not only did Notch not hear a response from Bethesda’s legal goon squad, he got a 15 page letter from them explaining that they are suing Mojang to stop them from using the name Scrolls and that they’ve already paid the Swedish courts for the case which I guess is the legal way of saying, “We’re not going to drop this, get your wallets ready.”
Notch is personally hoping this is just the legal machine at work about legal trademarks and not the creative minds of Bethesda and I’m hoping for that too. I mean, how could the creators of Oblivion and Fallout 3 act like this? Somebody at Bethesda is going to have to pass the buck several times to deflect the negative PR.
North Greenville Hospital Evacuation Assessment
IIE Annual Conference. Proceedings January 1, 2008 | Banks, James; Brenes, Jaclyn; Daniels, Lindsey; Childers, Ashley Kay; Taaffe, Kevin Abstract Healthcare facilities play a crucial role during emergencies by providing care to those in need. However, certain emergencies may require evacuating the existing patient population from the facility itself. There is often a lack of detailed processes, events, and resources available within a standard healthcare facility evacuation plan. The goal of this research is to develop an evacuation planning methodology for healthcare facilities that includes 1) a description of patient transfer processes, 2) time estimates for patient transfers, and 3) considerations for changes to these time estimates based on bed availability and emergency service vehicles within the healthcare network.
Industrial engineering, evacuation planning, resource utilization, healthcare, case study 1. Introduction This paper provides an analysis of the approach used thus far to help develop an evacuation planning methodology for healthcare facilities via a case study at North Greenville Hospital (NGH), a long-term care facility within the Greenville Hospital System in South Carolina. The research process thus far includes NGH’s approach to categorizing patients, patient placement within the hospital, current evacuation documentation and procedures, transportation procedures, and potential scenarios that could require patient transfers. The goal of this research is to create a National Incident Management System (NIMS) compliant evacuation plan for NGH that includes 1) a description of the patient transfer process by patient type, 2) time estimates for patient transfers, 3) considerations for changes to these time estimates based on the availability of beds at receiving hospitals and emergency service vehicles in the network. A closer look at NGH’s facility and emergency plans may lead to further developments in evacuation planning that can be applied throughout the Greenville Hospital System.
2. Background and Approach 2.1 Overview The Joint Commission, the national healthcare accreditation and certification organization, requires all healthcare facilities to have emergency or disaster plans to ensure that patient care can be continued . Facilities in the Greenville Hospital System (GHS) have met these requirements; however, these evacuation plans have not considered the variety of evacuation scenarios and the difficulties that may arise as decisions are made 2.2 North Greenville Hospital North Greenville Hospital (NGH) is a long term acute care hospital (LTACH) with 45 beds located in Traveler’s Rest, South Carolina. It provides treatment to patients ages 18 and older who require a stay in the hospital of more than 14 days. It serves a wide range of patients and offers a variety of treatments including cardiovascular treatment, respiratory, and kidney disease conditions; ventilator management; and antibiotic therapy . NGH and many other medical facilities in the area are all part of the Greenville Hospital System.
GHS has designated NGH as a primary triage point in the event of an epidemic such as pandemic flu that could affect Greenville and the surrounding areas. This would lead to the evacuation of NGH’s current LTACH patients to other facilities. With NGH serving as this emergency treatment center, the Creative Inquiry team will focus its efforts on assessing the ability to stage, transfer, and accompany these patients at other facilities.
2.3 Types of Facilities An acute care (AC) facility, is able to accept all types of patients. These are generally your large, multi-level hospitals. Greenville Memorial Hospital is an example of an AC facility. North Greenville Hospital is an example of an LTACH, or a long-term acute care hospital. These patients have a length of stay greater than 14 days and patients here are very critical. A mental hospital (MT), can only accept mentally ill patients. A skilled nursing facility, or SNF, employs skilled nurses. A nursing home is an example of a SNF. Patients here require less assistance and care than an AC or LTACH. go to web site greenville memorial hospital
3. Emergency Transfers Plans 3.1 Current Policies and Procedures The Greenville Hospital System has been working to become National Incident Management System, NIMS, compliant for the past few years. NIMS is a presidential directive that standardizes how federal, state, and local governments respond to disasters. Originally intended for government organizations, NIMS compliance has been extended to the healthcare industry, the Hospital Emergency Incident Command System (HEICS) is a model that many hospitals use to facilitate the transition to NIMS compliance . The remainder of this section explains the documents GHS uses to prepare for and manage disasters.
The GHS Emergency Management Plan  is a document that outlines the general management procedures which are to be followed in the event of an emergency. This document focuses on four phases of emergency planning: mitigation, preparedness, response, and recovery. GHS attempts to lessen the effects of large scale emergencies by performing periodic hazard vulnerability assessments, keeping staff trained on current emergency policies, employing redundant systems, and anticipating failures of the current system. After assessing a situation, the NIMSbased Hospital Incident Command System (HICS) is activated.
The GHS Emergency Operations Plan (EOP)  is a live document that identifies the strategy GHS uses to respond and recover from large scale emergencies. The EOP serves as a template for the implementation of the hospital incident command system (HICS) for those who have been trained in emergency management and preparedness. Each receiving campus within GHS has a HICS command center (HCC) with GMH (Greenville Memorial Hospital) acting as the central command point.
The GHS Disaster Manual  is a manual that is provided for house staff both online and in hard copy which advises all departments of specific procedures for responding to various emergencies. Information included in the Disaster Manual is the Emergency Management Plan, Hazard Vulnerability Analysis, emergency paging codes, mass patient discharge plan, hazmat plan, fire prevention plan, bomb threat plan, evacuation plan, severe weather plan, utility loss response, plans for loss of oxygen/medical gases, and supply support. The Disaster Manual serves as a quick reference for hospital staff that may not have been trained in emergency management and preparedness.
The North Greenville Hospital Emergency Preparedness Management Plan  is specific to North Greenville Hospital. Each facility in GHS is required to have an emergency management preparedness plan. Included in this document are sheltering, feeding, medication, transportation, and staffing plans. The document also contains the licensed capacity of the healthcare facility and the average census of patients as well as estimated total time for a complete evacuation of the facility.
4. Patient Transfer Procedures 4.1 Patient Types North Greenville Hospital categorizes patients by the type of treatment they are receiving. NGH is split into three halls: the 100, 200, and 300 Halls. Patients with similar treatment plans are placed on the same hall. The 100 Hall handles the most unstable patients. These patients are either on ventilators or hemodynamically unstable (unable to maintain a stable blood pressure. The 200 Hall of the hospital includes IV antibiotic and wound care patients. The 300 Hall houses hemodialysis patients and patients requiring various other treatments.
4.2 Current Methods The following depicts the current process for discharge as explained by personnel at NGH. In an effort to provide a more quantitative assessment of NGH’s evacuation plan, the staff was asked to provide time estimates for each task in that operation.
Currently, in non-emergency situations, patients are discharged to home health care, a Skilled Nursing Facility (SNF), or a rehabilitation center for therapy. Before a patient is discharged, the condition of the patient is discussed among care givers and caseworkers at NGH and a plan of action is established. Therapy notes, medical history, and physician’s orders are gathered from this consultation and placed electronically on the Extended Care Information Network (ECIN), a healthcare tool used to schedule transportation and discharges to the facilities listed above. All patient discharges, transportation times, and dates are confirmed on ECIN by both NGH and the receiving facility. If the receiving facility does not use ECIN, the network will fax all needed documentation to the facility and confirmation will be received via phone. The case handler also ensures that any special needs for treatment can be met at the receiving facility. The attending nurse will prepare the patient for discharge prior to the arrival of the scheduled transportation.
The current emergency preparedness management plan for NGH is frequently updated to maintain a working procedure for evacuation. In emergency situations NGH will activate a facility evacuation according to the GHS Disaster Manual in addition to following GHS HICS Command and other external resources. The facility will collaborate with the County Emergency Support Function (ESF) 8 Medical Annex Planning Group as part of the Greenville County Emergency Operations Center (EOC). The document also discusses sheltering, internal and external of GHS, transportation, and staffing plans .
Mass patient discharge will take place when the Operations Chief notifies the Human Services Director that beds are needed for incoming evacuation patients. During normal work hours staff with pre-assigned roles in emergency command will be notified. If it is after hours, staff will be called in according to recall procedures established by each department.
Before discharge, patient care preparations are to be conducted within the facility. An emergency preparedness packet will be provided to nursing units and will contain information concerning the discharging of patients to be evacuated. The Emergency Preparedness Discharge Coordinator, a nurse designated on each shift, is responsible for attaining instructions for the preparedness packet when an evacuation is in place. The packet includes the Patient Discharge/transfer Roster, the Patient Discharge Checklist, the Discharge Unit Coordinator Task List, a copy of the Mass Patient Discharge Procedure, and other necessary instructions.
When a mass discharge takes place, the Emergency Preparedness Discharge Coordinator will follow a screening process to prioritize patients for immediate discharge to home or other GHS facilities. As patients are chosen accordingly, their names are recorded on the Patient Discharge/Transfer Roster for tracking. This document is kept at the unit nursing station as well as with the Command Center “runner.” After identification of patients for discharge, nurses will begin preparation for transport. Patients will be transferred directly to the receiving facility if transportation is available; otherwise, patients will be placed in the discharge holding area at Roger C. Peace Hospital (RCPH). Nurses, therapists, and social staff will ensure all discharge operations are performed as well as acquire prescriptions, medical supplies, physicians’ orders, and coordinate community based services. The staff nurse will ensure the Discharge Check List, medical charts, and personal belongings stay with the patient. The nurse will contact family members to assist in discharge. The Social Work staff will assist in notifying the family about the patient’s discharge status. For home discharges, the patients will be picked up from NGH or the RCPH holding area. Home Health Coordinators will ensure appropriate home care procedure. Staff from RCPH will care for all patients in holding until they are discharged home or to another facility. After the evacuation from the facility is complete, a copy of the discharge roster will be forwarded to the Business Office for financial follow up with the patient. go to site greenville memorial hospital
5. Identifying Available Resources 5.1 Sheltering GHS has many sites within the hospital system that are capable of receiving and caring for evacuated patients. GHS’s policy is to first evacuate within the system and then use external hospitals as needed. Patients from an LTACH facility would be placed in shelters based on patient acuity, type, scope of disaster, and available beds. GHS facilities can accommodate approximately 126 LTACH patients. This is far more than is needed to evacuate the 45 patients housed at NGH; however, if the scale of a disaster affected multiple LTACHs across the region, external sheltering would be utilized. In addition, there is no guarantee that 126 beds will always be available (or that there would be adequate staff to support the increase in patient load.) The Mutual Aid and Sheltering Agreement (MASA) provides a list of facilities that have agreed to aid each other in the event of a large scale disaster. The MASA includes the name of each facility, location, licensure number, contact information, average daily census, and target number of available beds. Facilities accepting patients have agreed, under the MASA, to accommodate the new patients into their food plan. Medications, except for narcotics, will accompany the patient to the new facility. The patient will be provided enough medication to last 72 hours while at the new facility. After this time, the accepting facility will take over the dispensing of patient medication.
5.1.1 Available Beds During an evacuation, there are several types of facilities that are able to accept NGH patients. These facilities are included in the MASA document. NGH patients would not be evacuated to a MT. A SNF can accommodate most IV antibiotic patients and wound care patients. LTACHs are able to accept ventilator and hemodynamically unstable patients. It is also possible for an LTACH to accept patients with other treatment needs based on the facility. Acute Care Hospitals (AC) are able to accept all patient types.
NGH previously used a special program to help track the number and types of beds and the status of emergency, operating, and critical care units at facilities across the state. This hospital tracking program, HOSCAP, is updated daily or more frequently in an emergency situation. HOSCAP was primarily used by EMS to aid in decisions of where to send patients. In times of emergency, HOSCAP could be used to find hospitals able to accept evacuated patients. NGH has switched from HOSCAP to the State Medical Asset Resource Tracking Tool, SMARTT. SMARTT is a similar state based system that is currently being used by the North Carolina EMS. Both systems provide a quick and accurate snapshot of the current status of hospitals across the state.
NGH patients awaiting evacuation must be triaged and sent to a facility that can meet all their needs. In order to save time, patients in the 100 Hall can be sent to an Acute Care Hospital. The 100 wing contains the most critical patients and AC hospitals have all required resources to continue care for these patients. Patients in the 200 and 300 hallways must be triaged individually and sent to an appropriate facility. In the event of a no-notice evacuation, the current procedure at NGH is to evacuate least critical and ambulatory patients first, and then begin to evacuate the more critical patients out of the Emergency Room Bay. Some patients may be released and receive home care. Patients being released to home care exit out of the main entrance.
5.2 Transportation North Greenville Hospital uses the online Extended Care Information Network (ECIN) to request ambulances and transfers to other LTAC hospitals. This online system is linked to Mobile Care, who manages all ambulances in the Greenville Hospital System. There are many details that are still being researched-transport times from NGH to final evacuation destination, the full capabilities of the ECIN network, current evacuation plans for utilization of emergency vehicles, and times required to complete documentation of patient transfer.
5.3 Staffing During the evacuation, NGH’s goal is to maintain patient care. Depending upon acuity, GHS may send 1 RN or 1LPN, a patient care technician, clinical and support (lab, radiology, respiratory care, maintenance) as needed per 40 evacuated patients. Internal sheltering facilities also will provide on-site staff if available. Once patients are at the receiving hospital, staffing needs are reassessed.
During and after the evacuation process, staff is monitored for signs of fatigue and psychological stress by staff support director and employee health leaders. Reasonable work periods and nutrition are also addressed.
6. Case Studies It would be very difficult to predict North Greenville Hospital’s state at any given point leading up to or during an evacuation. Therefore, several cases have been modeled in order to anticipate problems that could arise in any of the scenarios. Table 1 below shows multiple cases that will need further investigation.
In these case studies, an estimated 20 minute loading and unloading time per patient (40 minutes total) is included in the total evacuation time analysis. NGH’s current policy is to evacuate patients to GHS facilities first, then evacuate to outside the system. These case studies reflect this methodology and assume one patient per ambulance. Bed availability at the receiving hospitals has been taken from the Mutual Aid and Sheltering Agreement, and a total capacity of 40 patients at NGH was used for simplicity in the analysis of these scenarios.
6.1 Case Study: Evacuation Scenarios with GMH as Primary Facility Assumptions:
* 20 minute loading and unloading time per patient (40 minutes total) * 1 patient per ambulance * Cases use 40 patients to represent NGH capacity * Travel times estimated with MASA document In Cases 1, 2, and 3, NGH evacuates 100% of patients to the nearest AC facility. Specifically, all 40 patients are evacuated to GMH. Each scenario calculates the total time required to evacuate NGH and the minimum number of ambulances required depending on the evacuation time window. The location of the receiving facility and the percent of patients that NGH sends to that facility also affect these statistics. It is important to note that Cases 1, 2, and 3 provide the same results whether Greenville Memorial Hospital has 100% or 50% of their beds available.
Cases 4, 5, 6, and 7 require 50% of patients to be evacuated to a SNF facility in addition to evacuating 50% of patients to an AC hospital. A total of thirty patients will evacuate to GMH because they also have a SNF unit that can accept 10 patients. AnMed is the closest SNF facility outside of GHS and can accept 10 patients. The remaining 10 patients at NGH are evacuated here.
Cases 8, 9, and 10 compare different cases where NGH patients require an evacuation to all four facility types including LTACH hospitals and patients requiring a discharge.
Case studies were not performed for the 0/0/50/50 (AC/SNF/LTACH/Discharge) scenarios and additional ones for the 25/25/25/25 because not enough LTACH and SNF hospitals are part of the Mutual Aid and Sheltering Agreement that would guarantee enough beds to satisfy a full evacuation of NGH.
As a result of these case studies, questions were raised on how ambulances will be utilized in an emergency situation. Will the minimum number of ambulances be used for the entire evacuation window, or will as many as available be used to shorten the total time of evacuation? Using additional ambulances may create additional problems. There must be enough staff and space in the emergency room bay to stage additional patients for transportation. Limited space in the emergency room bay and available medical staff could delay a patient transfer and add additional time to the overall evacuation. The evacuation process appears to run more smoothly if ambulance departure times are staggered to allow nursing staff time to stage patients throughout the evacuation period. It is not yet determined whether utilizing ambulances one way is preferred over another. Factors outside of the system regarding ambulance demand at other hospitals, true hospital bed availability, and Mobile Care’s decision-making process will affect how ambulances are utilized.
In the scenarios described above, NGH evacuates to only four hospitals overall. Some hospitals on the Mutual Aid and Sheltering Agreement are able to accept very few patients. Is it ideal to send patients to the closest facilities regardless of the large number of facilities that must be used, or is it better to limit the number of facilities used even though patients must be transferred farther? Considering transportation times, it appears that evacuating patients to the closest facilities and then to ones farther away allows more people to evacuate in a shorter amount of time. Further investigation is necessary to understand the time differences between preparing and executing discharges to multiple facilities as opposed to a single facility.
6.2 Case Study 2: Evacuation Scenarios without GMH as Primary Facility GMH is a huge resource in the first case study. Even if GMH could accept only half of the capacity of available beds, it would still be able to accommodate a full evacuation of NGH. However, if a regional disaster occurred that significantly lowered GMH’s bed availability, an evacuation of NGH would be significantly different. A second analyses of the cases described in Table 1 has been performed in order to see what the effect of this might be.
The results of these case studies showed the overall evacuation time was not compromised as long as all patients were sent to the closest ACs, each with 100% bed availability. This is possible because several other major AC hospitals are located in the surrounding areas. As bed percentages at receiving hospital decreased, the number of hospitals utilized increased. Sending patients to SNF and LTACH facilities dramatically increased the number of receiving facilities and the variability of the minimum number of ambulances required. These increases could jeopardize ease of transfer and increases the opportunities for mistakes.
7. Conclusions The research thus far has not only provided insight into the complexities of coordinating and executing a successful evacuation of healthcare facilities, but also exposed the lack of detailed processes, events, and resources available within a standard healthcare facility evacuation plan. Additional tools are being developed that perform this analysis more efficiently and will eventually have the capability to analyze any facility in the GHS. Further research is necessary to obtain more detailed data on processing times for patient discharge, transportation decisions, and system dynamics. This research hopes to develop an evacuation planning methodology for healthcare facilities, by applying information gathered from NGH to even larger, more complex healthcare facilities.
Acknowledgements This research has been partially supported by Clemson University’s Creative Inquiry Program. The Creative Inquiry Program provides a discovery oriented approach to learning for undergraduates, and it fosters collaboration among faculty, graduate, and undergraduate research within the Program.
[Reference] References 3. NIMS compliance 4. GHS Emergency Management Plan 5. GHS Emergency Operations Plan 6. GHS Disaster Manual 7. NGH Hospital Emergency Preparedness Management Plan [Author Affiliation] James Banks, Jaclyn Brenes, Lindsey Daniels, Ashley Kay Childers, Dr. Kevin Taaffe Department of Industrial Engineering Clemson University, Clemson, SC 29631, USA Banks, James; Brenes, Jaclyn; Daniels, Lindsey; Childers, Ashley Kay; Taaffe, Kevin